Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA ��1532 s 6z-Cz'�g�r�21 <br /> OWNER/OPERATQF� <br /> ////77[[((,, ' n CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME C U. ' <br /> Doti 6-e PLY 4q u V-I f O�' <br /> SITE ADDRESS i �Q!� r �7 cTa� <br /> 2- �C- Street Number Direction 1 V 1 t I re t Name[ S? �( Ci 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)6�9 {I /�/6� ��• I Z <br /> ZStreet Number V' �` 1 et Name <br /> CITYTr-61I ` STATE ZIP <br /> e <br /> PHONE#'I ExT. APN# LAND USE APPLICATION# <br /> (L�i) �� �7 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> &03 01 ( (7u r q. gq '- r'1L11ter^ . <br /> CONTRACTORI/ SERVICE RE UESTOR <br /> REQUESTOR CHECK if BILLING ADDRES <br /> Q- <br /> BUSINESS NAME , ` •� P��# � ! O �� Ex-r. <br /> HOME Or MAILING ADDRESSr� � / ,�.� � FAX# ) <br /> L � <br /> STATE ZIP / EMAILebirl UG C�/ _ ' 'e <br /> CITY `P '�(' <br /> BILLING ACKN WLEDGEMENT: I, the undersigned property or business owner, operator or uthorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br /> will be billed to me or my business as identified on this form. <br /> also certify that'I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> r <br /> APPLICANT'S SIGNATURE: DATE;KIZl 7- Z0z <br /> PROPERTY/BUSINESS OWNER OPERATOR GER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or operator of the property located at the above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It 'iLprovided to me or my <br /> representative. AY <br /> awl <br /> TYPE OF SERVICE REQUESTED: �(j`;(1 lJ� vinVl�Y iP ECE�V <br /> COMMENTS: <br /> EC 12 2023 <br /> SAN JOAQUIIV <br /> HS��EPgE ZAL N <br /> ACCEPTEDBY:"gv.i�� � �� EMPLOYEE#: DATE: `2 12�Z3 <br /> ASSIGNED TO: C k Ct.)-L i C� K EMPLOYEE#: DATE: 'Z( I-Z' 123 <br /> Date Service Completed (if already completed): SERVICE CODE: (�(�I PIE: <br /> Fee Amount:$1(,,2 Amount Paid /(o� �� Payment Date / I <br /> Payment TypeInvoice# Check# 3 3� (� Received By: <br /> EHD 48-02-025 $R FORM(Golden Rod) <br /> 03/22/23 `11 <br />